Changes in admission rates to an Aotearoa New Zealand hospital general medical service during COVID-19 lockdowns.

AIM: To better understand the reasons for reduced hospital admissions to a hospital general medicine service during COVID-19 lockdowns. METHODS: A statistical model for admission rates to the General Medicine Service at Wellington Hospital, Aotearoa New Zealand, since 2015 was constructed. This model was used to estimate changes in admission rates for transmissible and non-transmissible diagnoses during and following COVID-19 lockdowns for total admissions and various sub-groups. RESULTS: For the 2020 lockdown (n=734 admissions), the overall rate ratio of admissions was 0.71 compared to the pre-lockdown rate. Non-transmissible diagnoses, which constitute 87% of admissions, had an admission rate ratio of 0.77. Transmissible diagnoses, constituting 13% of admissions, had an admission rate ratio of 0.44. Reductions in admissions did not exacerbate existing ethnic disparities in access to health services. The lag in recovery of admission rates was more pronounced for transmissible than non-transmissible diagnoses. The 2021 lockdown (n=105 admissions) followed this pattern, but was of shorter duration with small numbers, and therefore measures were frequently not statistically significant. CONCLUSIONS: The biggest relative reduction in hospital admission was due to a reduction in transmissible illness admissions, likely due to COVID-related public health measures. However, the biggest reduction in absolute terms was in non-transmissible illnesses, where hospital avoidance may be associated with increased morbidity or mortality.

Patterns of asthma medication use and hospital discharges in New Zealand.

Background: In New Zealand a progressive increase in budesonide/formoterol dispensing, accompanied by a reduction in dispensing of short-acting ß2-agonists (SABAs), inhaled corticosteroids (ICSs), and other ICS/long-acting ß2-agonists (ICSs/LABAs), occurred in the 18-month period following publication of the 2020 New Zealand asthma guidelines, which recommended budesonide/formoterol anti-inflammatory reliever therapy. Objective: Our aim was to investigate more recent trends in asthma medication use and asthma hospital discharges in New Zealand. Methods: New Zealand national dispensing data for inhalers for the period from January 2010 to December 2022 were reviewed for patients aged 12 years and older. Monthly rates of dispensing of budesonide/formoterol, ICSs, other ICS/LABAs, and SABAs were displayed graphically by locally weighted scatterplot smoother plots. The rates of dispensing and hospital discharge for asthma were compared between the past 6 months for which dispensing data were available (July-December 2022) and the corresponding period from July to December 2019. Results: There has been a progressive increase in dispensing of budesonide/formoterol since 2019, with a 108% increase between the period from July to December 2019 and the period from July to December 2022 in adolescents and adults. In contrast, there was a reduction in rates of dispensing of other ICS/LABAs, ICSs, and SABAs by 3%, 18%, and 5%, respectively. During this period, there was a 17% reduction in hospital discharges for asthma. Conclusion: There has been a further widespread uptake of ICS/formoterol reliever and/or maintenance therapy in adolescents and adults with asthma in New Zealand. The changes in prescribing practice have been temporally associated with a reduction in hospital admissions for asthma.

The carbon footprint of as-needed budesonide-formoterol in mild asthma: a post hoc analysis.

INTRODUCTION: The use of pressurised metered-dose inhalers (pMDIs) and asthma exacerbations necessitating healthcare reviews contribute substantially to the global carbon footprint of healthcare. It is possible that a reduction in carbon footprint could be achieved by switching patients with mild asthma from salbutamol pMDI reliever therapy to inhaled corticosteroid-formoterol dry powder inhaler (DPI) reliever therapy, as recommended by the Global Initiative for Asthma (GINA). METHODS: This post hoc analysis included all 668 adult participants in the Novel START trial, who were randomised 1:1:1 to treatment with: as-needed budesonide-formoterol DPI, as-needed salbutamol pMDI, or maintenance budesonide DPI plus as-needed salbutamol pMDI. The primary outcome was carbon footprint of asthma management, expressed as kilograms of carbon dioxide equivalent emissions (kgCO2e), per person year. Secondary outcomes explored the effect of baseline symptom control and adherence (maintenance budesonide DPI arm only) on carbon footprint. RESULTS: As-needed budesonide-formoterol DPI was associated with 95.8% and 93.6% lower carbon footprint compared with as-needed salbutamol pMDI (least squares mean 1.1 versus 26.2 kgCO2e; difference -25.0, 95% CI -29.7 to -20.4; p<0.001) and maintenance budesonide DPI plus as-needed salbutamol pMDI (least squares mean 1.1 versus 17.3 kgCO2e; difference -16.2, 95% CI -20.9 to -11.6; p<0.001), respectively. There was no statistically significant evidence that treatment differences in carbon footprint depended on baseline symptom control or adherence in the maintenance budesonide DPI arm. CONCLUSIONS: The as-needed budesonide-formoterol DPI treatment option was associated with a markedly lower carbon footprint than as-needed salbutamol pMDI and maintenance budesonide DPI plus as-needed salbutamol pMDI.

START CARE: a protocol for a randomised controlled trial of step-wise budesonide-formoterol reliever-based treatment in children.

Background: Asthma is the most common chronic childhood respiratory condition globally. Inhaled corticosteroid (ICS)-formoterol reliever-based regimens reduce the risk of asthma exacerbations compared with conventional short-acting ß2-agonist (SABA) reliever-based regimens in adults and adolescents. The current limited evidence for anti-inflammatory reliever therapy in children means it is unknown whether these findings are also applicable to children. High-quality randomised controlled trials (RCTs) are needed. Objective: The study aim is to determine the efficacy and safety of budesonide-formoterol reliever alone or maintenance and reliever therapy (MART) compared with standard therapy: budesonide or budesonide-formoterol maintenance, both with terbutaline reliever, in children aged 5 to 11 years with mild, moderate and severe asthma. Methods: A 52-week, multicentre, open-label, parallel group, phase III, two-sided superiority RCT will recruit 400 children aged 5 to 11 years with asthma. Participants will be randomised 1:1 to either budesonide-formoterol 100/6 µg Turbuhaler reliever alone or MART; or budesonide or budesonide-formoterol Turbuhaler maintenance, with terbutaline Turbuhaler reliever. The primary outcome is moderate and severe asthma exacerbations as rate per participant per year. Secondary outcomes are asthma control, lung function, exhaled nitric oxide and treatment step change. Assessment of Turbuhaler technique and cost-effectiveness analysis are also planned. Conclusion: This will be the first RCT to compare the efficacy and safety of a step-wise budesonide-formoterol reliever alone or MART regimen with conventional inhaled ICS or ICS-long-acting ß-agonist maintenance plus SABA reliever in children. The results will provide a much-needed evidence base for the treatment of asthma in children.

Manuka oil based ECMT-154 versus vehicle control for the topical treatment of eczema: study protocol for a randomised controlled trial in community pharmacies in Aotearoa New Zealand.

BACKGROUND: Eczema is a chronic, relapsing skin condition commonly managed by emollients and topical corticosteroids. Prevalence of use and demand for effective botanical therapies for eczema is high worldwide, however, clinical evidence of benefit is limited for many currently available botanical treatment options. Robustly-designed and adequately powered randomised controlled trials (RCTs) are essential to determine evidence of clinical benefit. This protocol describes an RCT that aims to investigate whether a manuka oil based emollient cream, containing 2% ECMT-154, is a safe and effective topical treatment for moderate to severe eczema. METHODS: This multicentre, single-blind, parallel-group, randomised controlled trial aims to recruit 118 participants from community pharmacies in Aotearoa New Zealand. Participants will be randomised 1:1 to receive topical cream with 2% ECMT-154 or vehicle control, and will apply assigned treatment twice daily to affected areas for six weeks. The primary outcome is improvement in subjective symptoms, assessed by change in POEM score. Secondary outcomes include change in objective symptoms assessed by SCORAD (part B), PO-SCORAD, DLQI, and treatment acceptability assessed by TSQM II and NRS. DISCUSSION: Recruitment through community pharmacies commenced in January 2022 and follow up will be completed by mid-2023. This study aims to collect acceptability and efficacy data of manuka oil based ECMT-154 for the treatment of eczema. If efficacy is demonstrated, this topical may provide an option for a novel emollient treatment. The community-based design of the trial is anticipated to provide a generalisable result. ETHICS AND DISSEMINATION: Ethics approval was obtained from Central Health and Disability Ethics Committee (reference: 2021 EXP 11490). Findings of the study will be disseminated to study participants, published in peer-reviewed journal and presented at scientific conferences. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry (ANZCTR) ACTRN12621001096842. Registered on August 18, 2021 ( https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=382412&isReview=true ). PROTOCOL VERSION: 2.1 (Dated 18/05/2022).

COVID-19 infodemic and health-related quality of life in patients with chronic respiratory diseases: A multicentre, observational study.

Background: The explosion of information, misinformation and disinformation (the "infodemic") related to the coronavirus disease 2019 (COVID-19) pandemic on digital and social media is reported to affect mental health and quality of life. However, reports assessing the COVID-19 infodemic on health-related quality of life (HRQL) in patients with chronic diseases are scarce. In this study, we investigated the associations between the infodemic and HRQL in uninfected individuals with pre-existing chronic respiratory diseases (CRDs) such as asthma, chronic obstructive pulmonary disease (COPD) and other CRDs. Methods: We conducted a multi-national, cross-sectional, observational study in Canada, India, New Zealand and the United Kingdom where we distributed a set of digitised questionnaires among 1018 participants with chronic respiratory diseases who were not infected with the SARS-CoV-2 virus at least three months prior to the study. We collected information about the infodemic such as news watching or social media use more than usual during the pandemic. HRQL was assessed using the short form of the chronic respiratory questionnaire (SF-CRQ). Demographic information, comorbidities, compliance, mental health, behavioural function, and social support were also recorded. We analysed the direct and indirect relationships between infodemic and HRQL using structural equation models (SEM). Results: Of all participants, 54% were females and had a mean (standard deviation (SD)) age of 53 (17) years. We found that higher infodemic was associated with worse emotional function (regression coefficient ß = -0.08; 95% confidence interval (CI) = -0.14 to -0.01), which means a one SD change of the higher infodemic latent variable was associated with a 0.08 SD change of emotional function level. The association between higher infodemic and worse emotional function was mediated by worse mental health and behavioural functions but is marginally ameliorated by improved social support. In stratification analysis, we found significant disease and country-wise variations in the associations between infodemic and SF-CRQ domain scores. Conclusions: These results provide new evidence that the COVID-19 infodemic significantly influences the HRQL in patients with CRDs through a complex interplay between mental health, behavioural function, and social support. This new dimension of research also opens avenues for further research on infodemic-related health effects in other chronic diseases.

Anatomical distribution of endometriosis: A cross-sectional analysis of transvaginal ultrasound in symptomatic patients.

Purpose: The anatomical distribution of deep endometriosis (DE) is essential in treating patients with symptoms associated with the disease. There is an evidence gap in correlating clinical features and symptoms with disease patterns. The study aimed at determining DE anatomic distribution based on advanced transvaginal ultrasound and describe the relationship with symptoms obtained with the World Endometriosis Foundation Questionnaire. Methods: A cross-sectional study included 549 ultrasound results and 370 questionnaire responses between July 2018 and January 2021. Descriptive statistics are presented. Continuous variables were compared by a simple t-test and ANOVA and categorical variables by the chi-squared test. Logistic regression and R2 values summarised the relationship between positive ultrasound and possible predictor variables (software SAS version 9.4). Results: The anatomical locations with signs of endometriosis on ultrasound were the right uterosacral ligament (USL) 23.3% (n = 128), left USL 21.3% (n = 117) and bowel 19.1% (n = 105). Endometriomas in the right and left ovaries (14%, n = 77, and 14.7%, n = 81 respectively), superficial endometriosis in 15.5% (n = 85), torus uterinus in 11.7% (n = 64), Pouch of Douglas (POD) in 9.7% (n = 53), rectovaginal septum in 4.2% (n = 23), vaginal fornix in 3.5% (n = 19). A negative 'sliding-sign' was noted in 25.3% (n = 139), and ovarian medial immobility was noted frequently (left 20.2%, n = 111 and right 16.9%, n = 93). Dyspareunia, dysmenorrhoea, infertility and family history were associated with endometriosis lesions (P < 0.05). Prediction models based on symptomatology presented low discriminatory power. Discussion: This large real-life cohort associating the description of the anatomical distribution of endometriosis as seen on advanced TVS in symptomatic patients confirmed that uterosacral ligaments, torus uterinus, ovaries and bowel represent the most common anatomical sites of endometriosis. Also, the dynamic abnormalities elicited via ultrasound, such as the uterus 'sliding-sign' and ovarian mobility, remain common. The knowledge of the general locations of identifiable endometriosis on ultrasound and the dynamic abnormalities is essential to sonologists and sonographers in implementing advanced TVS protocols to detect endometriosis. In addition, the different presentations of dyspareunia can be associated with USL and bowel endometriosis. Subfertility might also be associated with USL, ovarian and bowel endometriosis. Nevertheless, prediction models showed suboptimal results. Conclusions: Endometriosis is mainly distributed in USLs, bowel and ovaries. POD obliteration is frequent. Symptoms can be associated with anatomic locations; however, prediction models showed low clinical applicability.

The Anti-Inflammatory Reliever (AIR) Algorithm Study: a protocol for a single-group study of an AIR stepwise approach to the treatment of adult asthma.

Background: The stepwise approach to long-term asthma management, which traditionally incorporates short-acting ß2-agonist reliever therapy, has been a core feature of asthma guidelines for over 30 years. There have been no studies, however, directly investigating the use of an entire guideline-recommended track. Recently, inhaled corticosteroid-formoterol has been recommended as the preferred reliever therapy in adult asthma, in accordance with a stepwise "Anti-Inflammatory Reliever" (AIR) treatment track. Objective: The aim of this study was to evaluate the AIR stepwise approach recommended by the New Zealand adolescent and adult asthma guidelines, in combination with a novel algorithm for transitioning between treatment steps. Methods: This 52-week, open-label, single-group study will recruit 100 adults aged 18 to 75 years with mild, moderate and moderate-severe asthma (ACTRN12620001010987). Participants will be allocated to budesonide-formoterol 200/6 µg, one actuation as needed (Step 1), one actuation twice daily and as needed (Step 2), or two actuations twice daily and one as needed (Step 3). Treatment steps will be adjusted throughout the study, in response to reliever use and asthma attacks, according to a stepwise AIR algorithm. Following a 26-week period of investigator-led transitions, participants will adjust their own treatment step. The primary outcome is participant satisfaction as measured by the Global Satisfaction score of the Treatment Satisfaction Questionnaire for Medication. Secondary outcomes will assess efficacy and safety, and describe patterns of medication use and participant flow through the treatment steps. Conclusion: This is the first trial to assess the AIR treatment track and algorithm. The results will provide knowledge to guide the clinical use of this approach.

The long-term impacts of COVID-19 on confirmed cases at least 12 months post-infection in Wellington, New Zealand: an observational, cross-sectional study.

AIM: To explore the prevalence of ongoing symptoms and laboratory abnormalities in confirmed cases of COVID-19 from the first wave within the Greater Wellington Region, after at least 12 months post infection. METHOD: COVID-19 cases were obtained from EpiSurv. Eligible participants electronically completed questionnaires (Overall Health Survey, Patient Health Questionnaire-9 [PHQ-9], Generalised Anxiety Disorder-7 [GAD-7], Pittsburgh Sleep Quality Index, EuroQol 5 Dimension 5 Level [EQ-5D-5L], Fatigue Severity Scale [FSS], WHO Symptom Questionnaire, Modified Medical Research Council Dyspnoea Scale [mMRC Dyspnoea Scale]). Blood samples were analysed for cardiac, endocrine, haematological, liver, antibody, and inflammatory markers. RESULTS: Forty-two of 88 eligible cases undertook the study. Participants were enrolled at a median 628.5 days from symptom onset. Fifty-two point four percent felt that their current overall health was worse than it was prior to contracting COVID-19. Ninety percent of participants reported at least two ongoing symptoms since their acute illness. Between 45-72% of participants reported each of anxiety, depression, dyspnoea, pain/discomfort, and sleep difficulties, assessed using the GAD-7, PHQ-9, mMRC Dyspnoea Scale, EQ-5D-5L and FSS questionnaires respectively. There were minimal laboratory abnormalities. CONCLUSION: There is a high prevalence of ongoing symptoms following the first wave of COVID-19 infection in Aotearoa New Zealand. At a median of 1.7 years post infection, there is a wide spectrum of symptoms and symptom severity, although as an observational, cross-sectional study a causal relationship between symptoms or their severity and COVID-19 infection cannot be firmly established.

Patterns of Asthma Medication Use in New Zealand After Publication of National Asthma Guidelines.

BACKGROUND: In June 2020, the New Zealand (NZ) adolescent and adult asthma guidelines recommended budesonide/formoterol, taken as maintenance and/or reliever therapy, as the preferred therapeutic approach. OBJECTIVE: To investigate whether these recommendations were associated with changes in clinical practice indicated by asthma medication use trends. METHODS: NZ national dispensing data for inhaler medications from January 2010 to December 2021 were reviewed. Monthly "dispensings" of inhaled budesonide/formoterol, inhaled corticosteroid (ICS), other ICS/long-acting ß2-agonists (LABA), and inhaled short-acting ß2-agonists (SABA), for the 12+ age group, were displayed graphically with piecewise regression used to produce plots of rates by time with a July 1, 2020, break point. The number of dispensings in the last 6 months that data were available (July-December 2021) was compared with the corresponding period, July-December 2019. RESULTS: Budesonide/formoterol dispensing increased markedly after July 1, 2020 (regression coefficient 41.1 inhalers dispensed/100,000 population per month [95% confidence interval (CI): 36.3-45.6, P < .0001]; 64.7% increase in the number of dispensings between July-December 2019 and July-December 2021), in contrast to "other ICS/LABA" (regression coefficient: -15.9 [95% CI: -22.2 to -9.6, P < .0001]; -1.7% decrease) and SABA (regression coefficient: -14.7 [95% CI: -29.7 to 0.3, P = .055]; -10.6% decrease), respectively. CONCLUSION: In NZ, a progressive increase in budesonide/formoterol dispensing, accompanied by a reduction in SABA and "other ICS/LABA" dispensing, occurred after publication of the 2020 NZ asthma guidelines. While acknowledging the limitations in the interpretation of temporal associations, these findings suggest that the transition to ICS/formoterol reliever-based therapy can be achieved if recommended and promoted as the preferred therapeutic approach in national guidelines.

Skin-to-deltoid-muscle distance at three recommended sites for intramuscular vaccination in a population with obesity: an observational study.

AIM: Worldwide, immunisation guidelines variably locate the deltoid injection site based on anatomical landmarks. This may influence the skin-to-deltoid-muscle distance and therefore the needle length required to achieve intramuscular injection. Obesity is associated with increased skin-to-deltoid-muscle distance, but it is unknown whether the injection site location chosen in individuals with obesity impacts the needle length required for intramuscular injection. The aim of the study was to estimate the differences in skin-to-deltoid-muscle distance between three different vaccine injection sites recommended by the national guidelines of the United States of America (USA), Australia and New Zealand, in obese adults. The study also explored i) the associations between skin-to-deltoid-muscle distance across the three recommended sites with sex, body mass index (BMI), and arm circumference, and ii) the proportion of participants with a skin-to-deltoid-muscle distance >20 millimetres (mm), in whom the standard 25mm needle length would not ensure deposition of vaccine within the deltoid muscle. METHOD: Non-interventional cross-sectional study in a single site, non-clinical setting in Wellington, New Zealand. Forty participants (29 females), aged ≥18 years, with obesity (BMI>30 kilograms [km]/m[[2]]). Measurements included distance from acromion to injection sites, BMI, arm circumference, and skin-to-deltoid-muscle distance measured by ultrasound at each recommended injection site. RESULTS: Mean (SD) skin-to-deltoid-muscle distances for USA, Australia and New Zealand sites were 13.96mm (4.54), 17.94mm (6.08) and 20.26mm (5.91) respectively, with a mean (95% confidence interval) for the distance between Australia minus New Zealand -2.7mm (-3.5 to -1.9), P<0.001; and USA minus New Zealand -7.6 mm (-8.5 to -6.7); P<0.001. Skin-to-deltoid-muscle distance was greater in females and was positively associated with BMI and arm circumference. The proportions with a skin-to-deltoid-muscle distance >20 mm were 45%, 40% and 15% for the New Zealand, Australia and USA sites respectively. However, the sample size was relatively small, limiting interpretation in specific sub-groups. CONCLUSION: There were marked differences in the skin-to-deltoid-muscle distance between the three recommended injection sites studied. When choosing the required needle length to achieve intramuscular vaccination in obese vaccine recipients, consideration needs to be given to the injection site location, sex, BMI and/or arm circumference, as these factors all influence the skin-to-deltoid-muscle distance. A standard needle length of 25mm may be insufficient to ensure deposition of vaccine into the deltoid muscle in a substantive proportion of adults with obesity. Research is urgently required to determine anthropometric measurement cut-points that can be used to enable appropriate needle length selection to ensure intramuscular vaccination.

Less Social Deprivation Is Associated With Better Health-Related Quality of Life in Asthma and Is Mediated by Less Anxiety and Better Sleep Quality.

BACKGROUND: Previous studies on health-related quality of life (HRQoL) in asthma have mainly focused on clinical and environmental determinants. Little is known about the role of social determinants on HRQoL in asthma. OBJECTIVES: We aimed to investigate the association between social deprivation and HRQoL in asthma. METHODS: A total of 691 adult asthmatics from Canada, India, New Zealand, and the United Kingdom were administered a digital questionnaire containing demographic information and questions about social and psychological attributes, sleep disturbances, and alcohol abuse. HRQoL was measured using the Short Form of the Chronic Respiratory Questionnaire (SF-CRQ). We analyzed the direct and indirect relationships between social deprivation and HRQoL using structural equation models with social deprivation as a latent variable. We tested for mediation via anxiety, depression, sleep disturbances, and alcohol abuse. RESULTS: We found that less social deprivation (latent variable) was directly associated with better SF-CRQ domain scores such as dyspnea (regression coefficient ß: 0.33; 95% confidence interval [CI]: 0.07 to 0.58), fatigue (ß: 0.39; 95% CI: 0.14 to 0.64), and emotional function (ß: 0.37; 95% CI: 0.11 to 0.62), but with the worse mastery score (ß: -0.29; 95% CI: -0.55 to -0.03); however, those associations varied across participating countries. We also observed that among all individual social deprivation indicators, education, companionship, emotional support, instrumental support, and social isolation were directly associated with HRQoL, and the relationship between social deprivation and HRQoL was mediated through anxiety and sleep disturbances. CONCLUSIONS: Our results demonstrated that less social deprivation was directly, and indirectly through less anxiety and better sleep quality, associated with better HRQoL in asthma.

The impact of diagnostic method on sense of control and powerlessness and social support in endometriosis patients-A retrospective cohort study.

INTRODUCTION: It is recognized that for individuals living with endometriosis, receiving a diagnosis is psychosocially beneficial, but little is known about whether this is influenced by the way in which the disease is diagnosed. The primary objective of this study was to determine the impact of the diagnostic test method (clinical, diagnostic imaging, or diagnostic laparoscopy) of endometriosis on the individual's sense of control over their disease and their perceived access to social supports. The secondary objectives were to identify the impact of the diagnostic method on perceived social support, and to explore if there was a difference in the diagnostic method utilization between countries. MATERIAL AND METHODS: This retrospective cohort study reports on data collected using the Endometriosis Health Profile-30 (EHP-30) section of a previously published larger survey conducted between May and July 2020. Women aged 18-55 years who had received a diagnosis of endometriosis were recruited by social media platforms. The two domains of interest on the EHP-30 were control and powerlessness and social support. Scores on these domains were analyzed with diagnosis method as the variable of interest. RESULTS: In all, 1634 valid survey responses were received. There was a small statistically significant difference found between control and powerlessness scores for patients that received a diagnosis via imaging (ultrasound/MRI; n = 120) vs clinical diagnosis (n = 121) (p = 0.049). However, this did not reach clinical significance when covariates were controlled for (p = 0.054). No other comparisons reached statistical significance. CONCLUSIONS: The diagnostic method of endometriosis does not appear to have a clinically significant impact on an individual's sense of control over their disease nor their access to social supports. However, further research into these domains to delineate the true impact of the diagnostic method is required.

External Validation of the "2021 AAGL Endometriosis Classification": A Retrospective Cohort Study.

STUDY OBJECTIVE: Externally validate the American Association of Gynecologic Laparoscopists (AAGL) staging system against surgical complexity and compare diagnostic accuracy with revised American Society for Reproductive Medicine (rASRM) stage, as was done in original publication. DESIGN: Retrospective, diagnostic accuracy study. SETTING: Multicenter (Sydney, Australia). PATIENTS: A total of 317 patients (January 2016-October 2021) were used in the final analysis. INTERVENTIONS: A database of patients with coded surgical data was analyzed. MEASUREMENTS AND MAIN RESULTS: Three independent observers assigned an AAGL surgical stage (1-4) as the index test and surgical complexity level (A-D) as the reference standard. Results from the most accurate of the 3 observers were used in the final analysis. The weighted kappa score for the overall performance of AAGL stage and rASRM to predict AAGL level was 0.48 and 0.48, respectively (no difference). This represents weaker agreement with AAGL level than was observed in the reference paper, which reported a weighted kappa of 0.62. Diagnostic accuracy (sensitivity, specificity, positive predictive value, and negative predictive value) for stage 1 to predict level A was 98.5%, 64.3%, 66.3%, and 98.3%; stage 2 to predict level B 31.2%, 90.5%, 27.0%, and 92.1 %; stage 3 to predict level C 12.3%, 94.1%, 59.3%, and 60.7%; stage 4 to predict level D 95.65%, 88.10%, 38.60%, and 99.62%. Area under the receiver operating characteristic curve for A vs B/C/D (cut point 9) was 0.87, A/B vs C/D (cut point 16) was 0.78, and A/B/C vs D (cut point 22) was 0.94. CONCLUSION: There was weak to moderate agreement between AAGL stage and AAGL surgical complexity level. Across all key indicators, the AAGL system did not perform as well in this external validation, nor did it outperform rASRM as it did in the reference paper. Results suggest the system is not generalizable.

COVID-19 vaccination and the skin to deltoid MUSCLE distance in adults with diabetes.

Objectives: To estimate the proportion of adult diabetics with a skin to deltoid muscle distance (SDMD) of > 25 mm, representing a distance greater than the standard needle length used for intramuscular COVID-19 vaccination, and to assess whether anthropometric measurements predict ultrasound SDMD measurements. Design: Non-interventional cross-sectional study. Setting: Single site, non-clinical setting, Wellington, New Zealand. Participants: One hundred participants (50 females) aged at least 18 years diagnosis with diabetes. All participants completed the study. Main outcome measures: The proportions of participants with a SDMD > 25 mm and a SDMD > 20 mm (indicating that the needle would not have penetrated at least 5 mm into the deltoid, which is considered necessary to ensure deposition of vaccine into muscle); the relationship between anthropometric measurements (body weight, body height, body mass index (BMI), skinfold thickness, arm circumference) and SDMD measured by ultrasound. Results: The proportion (95 %CI) of participants with a SDMD > 25 mm was 6/100; 6 % (2.2 to 12.6), and the proportion with a SDMD > 20 mm was 11 % (5.6 to 18.8), of which 9/11 had a BMI ≥ 30 kg/m2 and 9/11 were female. The strongest relationships between anthropometric measurements and SDMD were with arm circumference (r = 0.76, P < 0.001) and BMI (r = 0.73, P < 0.001). Arm circumference and BMI were the best predictors of SDMD measurements with AUC for ROC curves of 0.99 and 0.94 above the 25 mm cut point, 0.97 and 0.89 above the 20 mm cut point respectively. Conclusions: The standard needle length of 25 mm is likely to be insufficient to ensure deposition of COVID-19 vaccine within the deltoid muscle in a small but important proportion of obese adults with diabetes. Arm circumference and BMI are simple measurements that could identify those that need a long needle to ensure successful intramuscular vaccine administration. Funding: Ruth Maud Ring Spencer Estate; Health Research Council of New Zealand (Independent Research Organisation).

Asthma control with ICS-formoterol reliever versus maintenance ICS and SABA reliever therapy: a post hoc analysis of two randomised controlled trials.

BACKGROUND: In randomised controlled trials, as-needed inhaled corticosteroid (ICS)-formoterol reliever therapy reduces severe exacerbation risk compared with maintenance ICS plus short-acting beta2-agonist (SABA) reliever in adolescent and adult asthma, but results in slightly worse control of asthma symptoms, as measured by mean Asthma Control Questionnaire-5 (ACQ-5) score. OBJECTIVE: To assess the levels and changes in asthma control for as-needed budesonide-formoterol versus maintenance budesonide plus SABA in post hoc analyses from the Novel START and PRACTICAL clinical trials. METHODS: The number and proportion of participants at study end in each ACQ-5 category ('well-controlled', 'partly controlled' or 'inadequately controlled' symptoms), and in each responder category based on the minimal clinically important difference for ACQ-5 of 0.5 (improved, no change and worse) with as-needed budesonide-formoterol and maintenance budesonide plus SABA treatment were calculated. RESULTS: With last observation carried forwards, 189/214 (88.3%) and 354/434 (81.6%) of patients in the budesonide-formoterol group had 'well-controlled' or 'partly controlled' symptoms at the end of the study, vs 183/214 (85.5%) and 358/431 (83.1%) in the budesonide maintenance group, for Novel START and PRACTICAL, respectively. The proportion of patients whose symptom control was either improved or unchanged from baseline was 190/214 (88.8%) and 368/434 (84.8%) for budesonide-formoterol, vs 185/214 (86.4%) and 376/431 (87.2%) for maintenance budesonide, in Novel START and PRACTICAL respectively. CONCLUSIONS: There were no clinically important differences in the proportions of patients with 'well-controlled' or 'partly controlled' asthma symptoms, or proportions who improved or maintained their level of control, with as-needed budesonide-formoterol versus maintenance budesonide plus SABA.

Estimating the prevalence of drawing in clinical practice among kiwi doctors.

Drawing has played a key role in the development and dissemination of Medicine and Surgery, such as to share anatomy, pathology, and techniques for clinical interventions. While many of the visuals used in medicine today are created by medical illustration professionals, and by imaging techniques such as photography and radiography; many doctors continue to draw routinely in their clinical practice. This is known to be valued by patients, for example when making informed decisions about care. We surveyed doctors in New Zealand online regarding their use of drawing to explore the prevalence of this practice. 472 complete responses were obtained over 3 months. There were very high rates of drawing among responding doctors practicing in both medical and surgical specialties. Reasons for drawing are explored and included professional, collegial, and patient communication, supporting informed consent, clinical documentation, and for planning procedures. Widespread use of drawing in clinical practice, almost non-existent training or support for this in digital workflows, and high interest in resources to develop clinical drawing skills, suggest unmet training needs for this practical clinical communication tool.

Efficacy of a 3% Kanuka oil cream for the treatment of moderate-to-severe eczema: A single blind randomised vehicle-controlled trial.

Background: Maori, the indigenous people of New Zealand, have traditionally used the kanuka tree as part of their healing system, Rongoa Maori, and the oil from the kanuka tree has demonstratable anti-inflammatory and anti-bacterial properties. This trial investigated the efficacy and safety of a 3% kanuka oil (KO) cream compared to vehicle control (VC) for the topical treatment of eczema. The trial was conducted through a nationwide community pharmacy research network. Methods: This single-blind, parallel-group, randomised, vehicle-controlled trial was undertaken in 11 research trained community pharmacies across New Zealand. Eighty adult participants with self-reported moderate-to-severe eczema, assessed by Patient Orientated Eczema Measure (POEM) were randomised by blinded investigators to apply 3% KO cream or VC topically, twice daily, for six weeks. Randomisation was stratified by site and eczema severity, moderate versus severe. Primary outcome was difference in POEM scores at week six between groups by intention to treat. The study is registered on the Australian New Zealand Clinical Trial Registry (ANZCTR) reference number, ACTRN12618001754235. Findings: Eighty participants were recruited between 17 May 2019 and 10 May 2021 (41 KO group, 39 VC group). Mean POEM score (standard deviation) improved between baseline and week six for KO group, 18·4 (4·4) to 6·8 (5·5), and VC group, 18·7 (4·5) to 9·8 (6·5); mean difference between groups (95% confidence interval) was -3·1 (-6·0 to -0·2), p = 0·036. There were three adverse events reported in the KO group related to the intervention and two in the control group. Interpretation: The KO group had a significant improvement in POEM score compared to VC. Rates of adverse events and withdrawals were similar between groups with no serious adverse events reported. Treatment acceptability was high for both groups across all domains. Our results suggest that in adults with moderate-to-severe eczema, the addition of KO to a daily emollient regimen led to a reduction in POEM score compared to VC. KO may represent an effective, safe, and well tolerated treatment for moderate-to-severe eczema in adults. Funding: Hikurangi Bioactives (Ruatoria, New Zealand) and HoneyLab (Tauranga, New Zealand), supported by a grant from Callaghan Innovation.

Cannabis in Palliative Care: A Systematic Review of Current Evidence.

CONTEXT: Palliative care aims to improve the quality of life in patients with incurable illness. Medicinal cannabis (MC) has been used in the palliative care setting to address multiple symptoms in patients. OBJECTIVES: To evaluate the full scope of available literature investigating the effects and potential harms of MC on symptom management and quality of life in palliative care. METHODS: PubMed, Embase, The Cochrane Library and clinicaltrials.gov were searched for eligible articles, published between 1960 and September 9, 2021. Quality of the evidence was assessed in accordance with Grading of Recommendations, Assessment, Development and Evaluations. Risk of bias was assessed using the RoB 2 tool for randomised controlled trials and the Risk of Bias in Non-randomized Studies-of Interventions (ROBINS-I) tool for non-randomized trials. RESULTS: Fifty-two studies (20 randomised; 32 non-randomised) with 4786 participants diagnosed with cancer (n = 4491), dementia (n = 43), AIDS (n = 235), spasticity (n = 16), NORSE syndrome (n = 1) were included. The quality of evidence was 'very low' or 'low' for all studies, and low for only two randomised controlled trials. Positive treatment effects (statistical significance with P < 0.05) were seen for some MC products in pain, nausea and vomiting, appetite, sleep, fatigue, chemosensory perception and paraneoplastic night sweats in patients with cancer, appetite and agitation in patients with dementia and appetite, nausea and vomiting in patients with AIDS. Meta-analysis was unable to be performed due to the wide range of cannabis products used and the heterogeneity of the study outcomes. CONCLUSION: While positive treatment effects have been reported for some MC products in the palliative care setting, further high quality evidence is needed to support recommendations for its use in clinical practice.

How best to share research with study participants? A randomised crossover trial comparing a comic, lay summary, and scientific abstract.

Healthcare research is traditionally published in academic papers, coded in scientific language, and locked behind paywalls - an inaccessible form for many. Sharing research results with participants and the public in an appropriate, accessible manner, is an ethical practice directed in research guidance. Evidence-based recommendations for the medium used are scant, but science communication advice advocates principles which may be fulfilled well by the medium of comics. We report a randomised crossover study conducted online, comparing participant preferences for research results shared in the medium of a comic, a traditional lay text summary, and the control approach of a scientific abstract. 1236 respondents read all three summaries and ranked their most and least preferred formats. For the most preferred summary, the comic was chosen by 716 (57.9%), lay summary by 321 (26.0%), and scientific abstract by 199 (16.1%) respondents. For the least preferred summary the scientific abstract was chosen by 614 (49.7%), lay summary by 380 (30.7%) and comic by 242 (19.6%). Review of free-text responses identified key reasons for the majority preferring the comic over the others, which included finding this easier to read and understand, more enjoyable to consume, and more satisfactory as a medium of communication.